Cornea and External Disease
Refractive Surgery/Lasik

A Healthy Corneal Surface Helps Ensure Optimal Lasik Outcomes

Posted on

An emphasis on education ensures patients understand the importance of optimizing the ocular surface before and after corneal refractive surgery.

By Lisa K. Feulner, MD, PhD

Femtosecond-assisted wavefront-guided LASIK is a safe and effective procedure for refractive correction with a very high rate of patient satisfaction.1,2 Dry eye, however, commonly affects a large number of patients to varying degrees in the immediate postoperative period.3 Left untreated, ocular surface disease can not only derail patients expected visual outcomes, but also their short- and long-term comfort. Conscientious attention to and treatment of the ocular surface will help patients achieve a lifetime of great vision.

Corneal refractive patients often present for surgery because they are experiencing contact lens discomfort and intolerance. This is an obvious red flag for ocular surface problems.  Identifying and treating ocular surface disease before refractive (and cataract) procedures is important to ensure patients’ postoperative outcomes are optimal and their expectations are appropriate. They must be informed before surgery that they have this issue so that they do not perceive that the surgery created the problem.

As part of my complete evaluation, I ask contact lens wearers why they have stopped wearing their contacts, taking note of how they say their eyes feel throughout the day and asking about fluctuating vision. I perform the slit lamp exam, taking care to assess the lid margins and the corneal surface with all my available tools. This includes corneal topography with Placido rings that can reveal irregularities, Schirmer’s testing, evaluating staining patterns, measuring tear breakup time, and checking tear lake height. I include osmolarity and MMP-9 testing for inflammatory markers. All of this helps me pinpoint what specific treatment is necessary for each individual patient before surgery.

Another benefit of this comprehensive workup is it helps to show patients that having LASIK is not an insignificant process—it is much more than a matter of putting them under a laser and “zapping” their corneas. I make sure they understand the need to address the ocular surface preoperatively and continue treatment postoperatively so they can have the vision they seek, long-term comfort, and satisfaction with their procedure.

Using Analogies
When it comes to ocular surface disease treatments, patients often ask, “Do I have to do this,” or “When can I stop” these therapies? To explain, I use easily understandable analogies. I would say, if you bought a Porsche, you know that for peak performance you need to keep up with maintenance like properly inflating the tires, getting the engine tuned, and changing the oil. For an optimal result from a Porsche-like surgery, we must maintain your cornea. Patients spend a significant amount of money on LASIK, and we use advanced technology to create their desired visual outcome. To maintain that result over the long term, I stress the importance of supporting their investment by keeping their corneal surface tuned up over their lifetime.

My staff and I take our preoperative regimen and customized treatments very seriously. Making this work requires practice-wide buy-in from the technicians to the surgical coordinator to everybody in between. We ask surgical patients to sign a specially created dry eye management form. We give them a copy and put a copy in their chart. I emphasize with them that we have documented the protocol, designed especially for them, and they need to follow it as closely as possible to ensure that I can deliver the outcome that they expect. Although young patients might be geared toward instant gratification, this process underscores how serious we are and how critical it is that we deal with ocular surface issues first.

We spend a lot of time on patients’ pre-op education. I also use a plethora of visual information to help them understand why we are doing what we are doing. By showing them topography with Placido rings, meibography, osmolarity, and MMP-9 results, I can illustrate the problem and increase their acceptance of a possible delay in the procedure due to ocular surface irregularities. Education continues to be key when I need to add on treatments. I describe the components of the tear film and their effect on vision and ocular surface health. I tell them we treat all three layers for a smooth ocular surface that provides accurate measurements necessary for excellent visual results.

Inflammation is at the Root
Quelling inflammation on the ocular surface is the unifier of my treatments. Like with inflammation due to an injury elsewhere in the body, I tell patients we need to break that inflammatory cycle to heal. That helps them understand that they have a disease that requires more than temporary, symptomatic relief with artificial tears. We focus on elevating the concept, telling them they have ocular surface disease—we rarely use the term dry eye. The media often leads people to believe dry eye is no big deal and can be cured with Visine, for example. It takes significant effort and education to get patients to commit to their preoperative treatment regimen, even more so for postoperative therapy. Because patients are seeking evidence-based therapies, I provide resources that let them go online and see the data that supports their specific plan.

Asymptomatic patients with findings upon testing are the most challenging to treat. They should be handled in a very stepwise fashion as they may be more resistant to the immediate layering of therapy. As far as they are concerned, they do not have a problem. Showing them visual evidence of their disease is helpful, but for these individuals, I find I have more success if I take it more slowly picking and choosing therapy as to not overwhelm them. Highly symptomatic patients, on the other hand, are the easiest to care for. They are suffering, they are uncomfortable, and they want to have the surgery therefore they are eager and motivated.

Nutritional Therapy
Patients often think of pills as working immediately—they take a pill for high blood pressure today and tomorrow their blood pressure is lower. A challenge with a nutraceutical is explaining that it takes time to make a difference; maximum therapeutic effect is usually reached after 2 to 3 months, though patients usually notice an improvement in 3 to 5 weeks. Although they may experience a change in their ocular surface preoperatively, it is in the postoperative period that they are going to get the most benefit. I often prescribe an anti-inflammatory eye drop as well to achieve more immediate results, so patients know I am just as eager to move them through this process as they are.

We also must navigate the hurdle of differentiating for them supplements they can get easily at any drug store, versus something like HydroEye (ScienceBased Health) with its specific formula that combines ingredients to achieve clinically significant improvements in the ocular surface. Primary care doctors tell patients they should be taking omega-3s, but they often do not specify which type or why. In my experience, they do not educate on omega-6s at all. Patients might say they have tried omega-3s and did not like the side effects or they did not feel any improvement, so they stopped taking it. Some may say I’m good I already take something.

Here is where I find it easy to explain why HydroEye is different. It is uniquely designed to support the ocular surface with anti-inflammatory effects along different pathways that improve the tear film. It is not just a higher-quality omega-3 product. I can provide specific evidence for how it works, and this helps patients understand it is superior; HydroEye has been a game changer for me. Because these younger patients value clinical data and references, I share links to peer review studies that explain the function of HydroEye’s components. The patented formula contains the fatty acid gamma-linolenic acid (GLA), derived from black currant seed oil. Helping to modulate the body’s inflammatory response, this compound cannot be obtained through diet, regardless of how much salmon, flaxseed, or other fish oil they consume.4 GLA has been shown to improve dry eye symptoms in a of variety studies,5-10 and HydroEye has been specifically validated in a randomized, controlled clinical trial.11 I also tell patients this nutraceutical has anti-inflammatory qualities that benefit overall health in addition to the eyes.

The chances of a 25- to 35-year-old patient taking a prescription anti-inflammatory eye drop consistently for the long term are slim, it is an inconvenience, and it becomes expensive. Supplements on the other hand are widely accepted and likely something they are already doing. With HydroEye’s long-term anti-inflammatory benefits, patients are supporting their ocular surface health and ensuring a more successful surgical outcome.

We sell the product among several other therapies in our office. We are very comfortable with retail, and we find that patients like to leave with something in their hand. After the initial supply of HydroEye, they can go directly to the manufacturer’s website for reordering convenience.

There has been a significant amount of negative media attention around “LASIK causing dry eye.” Surgeons must address the ocular surface in refractive surgery patients and they, along with patients, must buy into the importance of doing so. When eye care providers do not proactively treat the ocular surface and educate patients about the sustained benefits on outcomes and long-term success, they risk suboptimal results and unhappy patients. Physicians must also be comfortable telling patients when they are not good candidates for LASIK, no matter what treatments are used. I make sure they know I am still going to take care of their ocular surface.


Lisa K. Feulner, MD, practices at Advanced Eye Care & Aesthetics in Bel Air, Maryland. She may be reached at [email protected]. Dr. Feulner is a consultant to and a speaker for ScienceBased Health.


  1. Solomon KD, Fernández de Castro LE, Sandoval HP, et al; Joint LASIK Study Task Force. LASIK world literature review: quality of life and patient satisfaction. Ophthalmology. 2009;116(4):691-701. doi: 10.1016/j.ophtha.2008.12.037.
  2. Tanzer DJ, Brunstetter T, Zeber R, et al. Laser in situ keratomileusis in United States Naval aviators. J Cataract Refract Surg. 2013;39(7):1047-58. doi: 10.1016/j.jcrs.2013.01.046
  3. Shtein RM. Post-LASIK dry eye. Expert Rev Ophthalmol. 2011; 6(5): 575-582. doi: 10.1586/eop.11.56.
  4. Kapoor R, Huang YS. Gamma linolenic acid: an antiinflammatory omega-6 fatty acid. Curr Pharm Biotechnol. 2006;7(6):531-534. doi:10.2174/138920106779116874.
  5. Barabino S, Rolando M, Camicione P, et al. Systemic linoleic and gamma-linolenic acid therapy in dry eye syndrome with an inflammatory component. Cornea. 2003;22(2):97-101. doi:10.1097/00003226-200303000-00002.
  6. Macrì A, Giuffrida S, Amico V, et al. Effect of linoleic acid and gamma-linolenic acid on tear production, tear clearance and on the ocular surface after photorefractive keratectomy. Graefes Arch Clin Exp Ophthalmol. 2003;241(7):561-566. doi:10.1007/s00417-003-0685-x .
  7. Aragona P, Bucolo C, Spinella R, et al. Systemic Omega-6 essential fatty acid treatment and pge1 tear content in Sjögren’s syndrome patients. Invest Ophthalmol Vis Sci. 2005;46(12):4474-4479. doi:10.1167/iovs.04-1394
  8. Kokke KH, Morris JA, Lawrenson JG. Oral omega-6 essential fatty acid treatment in contact lens associated dry eye. Cont Lens Anterior Eye. 2008;31(3):141-146. doi:10.1016/j.clae.2007.12.001.
  9. Pinna A, Piccinini P, Carta F. Effect of oral linoleic and gamma-linolenic acid on meibomian gland dysfunction. Cornea. 2007;26(3):260-264. doi:10.1097/ICO.0b013e318033d79b.
  10. Brignole-Baudouin F, Baudouin C, Aragona P, et al. A multicentre, double-masked, randomized, controlled trial assessing the effect of oral supplementation of omega-3 and omega-6 fatty acids on a conjunctival inflammatory marker in dry eye patients. Acta Ophthalmol. 2011;89(7):e591-7. doi10.1111/j.1755-3768.2011.02196.x.
  11. Sheppard JD Jr, Singh R, McClellan AJ, et al. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea. 2013;32(10):1297-1304. doi:10.1097/ICO.0b013e318299549c